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Delivering person-centered care with an electronic health record.

ABSTRACT: BACKGROUND:Electronic health records are now widely adopted in medical and behavioral health settings. While they have the potential to improve the quality of care, the research findings on their impact on clinical practice and outcomes have been mixed. This study explores how the electronic health record and its stage of development influenced the implementation of person-centered care planning in community mental health clinics. METHODS:The study was set in five community mental health clinics which utilized an EHR and had been trained in person-centered care planning. Using an objective quantitative measure of fidelity, the study examined fidelity to PCCP across time and by stage of EHR development. Data from focus groups, interviews with clinic leaders and consultant reports was analyzed to explore the process of implementation and the role of the electronic health record. RESULTS:All clinics demonstrated an overall increase in PCCP fidelity at the conclusion of the study period but there were significant differences in PCCP fidelity among clinics with EHRs in different stages of development. Electronic health records emerged as a significant implementation factor in the qualitative data with clinics being unable to individualize service plans and encountering technical difficulties. Barriers to person-centered care included drop-down boxes and pre-determined outcomes. Clinic responses included customizing their record or developing workarounds. CONCLUSIONS:The study demonstrated the need to align the electronic health record with a person-centered approach which includes individualizing information and orienting service plans to personal life goals. The ability of clinics to be able to customize their records and balance the need for unique and aggregate information in the record is critical to improve both the provider experience and the quality of care. TRIAL REGISTRATION:Clinicaltrials.gov , NCT02299492 , registered on November 24, 2014.

SUBMITTER: Stanhope V

PROVIDER: S-EPMC6704707 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Delivering person-centered care with an electronic health record.

Stanhope Victoria V Matthews Elizabeth B EB

BMC medical informatics and decision making 20190822 1

<h4>Background</h4>Electronic health records are now widely adopted in medical and behavioral health settings. While they have the potential to improve the quality of care, the research findings on their impact on clinical practice and outcomes have been mixed. This study explores how the electronic health record and its stage of development influenced the implementation of person-centered care planning in community mental health clinics.<h4>Methods</h4>The study was set in five community mental ...[more]

PMID: 31438960

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Project description:BackgroundIncorporating a patient's personal narrative into the electronic health record is an opportunity to more fully integrate the patient's values and beliefs into care, thus creating opportunities to deliver high-quality/high-value, person-centered care.ObjectivesThe aim of the study was to present a study protocol of a narrative intervention to (a) compare the effects of the narrative intervention to usual care on primary outcome of person's (patient) perceptions of quality of communication, (b) compare the effects of the narrative intervention on secondary outcomes of biopsychosocial well-being, and (c) examine the feasibility and acceptability of the narrative intervention from the perspective of both persons: the patient and the acute care bedside nurse.MethodsA randomized control trial is being conducted with a targeted enrollment of 80 patient participants and 80 nurse participants. The patient participants include individuals who are admitted to the acute care hospital for either heart failure or end-stage renal disease. An acute care beside nurse who has cared for the patient participant is also enrolled. Through a 1:1 random allocation scheme, stratified by illness, we will enroll 40 in the narrative intervention group and 40 in the usual care group. Patient participants will be assessed for patient-reported outcomes of patient's perception of quality of communication and biopsychosocial well-being.ResultsThe study began in October 2019; 53 potential patient participants have been approached, 21 have enrolled, and 20 have completed the data collection process.DiscussionThe testing and integration of a person-centered narrative into the electronic health record is a novel approach to provide opportunities for improvement in communication between patients and nurses. The results from this study will provide important preliminary knowledge to inform future randomized clinical trials of narrative interventions leading to advances in how to best provide high-value, high-quality, person-centered care for persons living with serious illness.

Project description:BackgroundMental health care (MHC) needs to shift towards person-centered care to better meet people's individual needs. Open Dialogue (OD) is well-aligned with this perspective and brings it into practice. This study focuses on exploring the change process within a pilot project involving three MHC teams as they transition to a person-centered OD practice. Our aim is to identify and reflect on the challenges faced by MHC professionals in adopting person-centered care, and shedding light on the underlying complexity of these challenges. By gaining a better understanding of these obstacles, we hope to contribute to the adoption of the person-centered approach in MHC practice.MethodsOur research employed a qualitative design, involving a total of 14 semi-structured interviews with MHC professionals who were either trained in OD, OD trainees, or MHC professionals without OD training. To analyze the data, we utilized a hybrid approach that combined deductive - and inductive thematic analysis.ResultsWe identified four distinctive challenges: (1) understanding and knowledge transfer, (2) (inter)personal process, (3) emotional discomfort, and (4) the need for multi-stakeholder participation and support. In practice, these challenges intersect and the appearance of and relationships between these challenges are not linear or disentangleable.ConclusionUpon careful consideration of these interdependent challenges, it became evident that embedding a person-centered approach like OD brings about systemic change, leading to an unfamiliar situation X. The research findings indicated that understanding and conveying the concept of person-centered care in practical settings poses significant challenges. The field of knowledge management helps to capture the complexity of understanding and transferring this knowledge. The change process necessitates an (inter)personal process and elicits emotional discomfort, as person-centered OD practice confronts a deeply entrenched paradigm in MHC. Achieving a shared understanding of person-centered care requires dedicated time and attention, while introducing this approach prompts broader discussions on underlying values and human rights in MHC. Current implementation efforts may underestimate or overlook these underlying values, but initiating an open dialogue can serve as an initial step in addressing the complexities.

Project description:Rationale & objectiveElectronic health record portals are increasingly emphasized in chronic kidney disease (CKD). However, associations of portal use with clinical and patient-centered outcomes remain unknown.Study designCross-sectional survey (April 2015 to March 2018).Setting & participantsNondialysis patients with CKD from nephrology clinics within 1 academic medical center.ExposuresPatient demographics (age, sex, race, ethnicity, education, and income), kidney function.OutcomesAssociation between portal use as an outcome and exposures. Additionally, associations of portal use and patient demographics with 4 patient-centered outcomes (CKD-specific knowledge, stress, and 2 self-ratings of health).Analytic approachLogistic regression to examine associations between patient portal use, demographics, and kidney function. Linear regression to examine associations between portal use and patient-centered outcomes.ResultsOf 245 participants, mean age was 60 ± 17 (SD) years, 182 (77%) were White, 121 (49%) were women, 230 (96%) had a high school education or higher, and 96 (45%) had <$50,000 annual income. Examining portal use, 159 (65%) used the portal as follows: checking laboratory test results, 157 (99%); managing appointments, 133 (84%); messaging providers, 131 (82%); viewing medical history, 127 (80%); reviewing educational resources, 113 (71%); and renewing prescriptions, 98 (62%). African Americans (OR, 0.34; 95% CI, 0.16-0.72 vs White patients), patients with less formal education (OR, 0.06; 95% CI, 0.01-0.36), and those with lower income (OR, 0.28; 95% CI, 0.13-0.60; and OR, 0.26; 95% CI, 0.12-0.54 comparing income < $25,000 and $25,000-$50,000, respectively, with ≥$50,000) had lower odds of using the portal. In adjusted analysis, only lower income predicted lower portal use. Examining patient-centered outcomes in univariable analysis, portal users had higher knowledge (β = 4.89; P = 0.02), higher ratings of current health (β = 0.28; P = 0.03), and lower CKD-related stress (β = -0.18; P = 0.05). In adjusted analysis, only patient demographics and/or kidney function remained independent predictors of patient-centered outcomes.LimitationsCross-sectional study design, cannot determine causality.ConclusionsInterventions are needed to ensure that all patients have access to portals to mitigate disparities in care.

Project description:BackgroundMultiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload.ObjectiveTo estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes.DesignQuality improvement quasi-experiment, analyzed as interrupted time series.ParticipantsAdult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers.InterventionIn the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription.Main measuresProportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions.Key resultsAcross the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards.ConclusionsAutocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress.Trial registrationwww.ClinicalTrials.gov protocol 1710018646.

Project description:Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential.Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases.The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources--selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans.The IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care.Clinicaltrials.gov identifier: NCT00589173.

Project description:BackgroundPerson-centered care is needed to effectively support workers with chronic health conditions. Person-centered care aims to provide care tailored to an individual person's preferences, needs and values. To achieve this, a more active, supportive, and coaching role of occupational and insurance physicians is required. In previous research, two training programs and an e-learning training with accompanying tools that can be used in the context of person-centered occupational health care were developed to contribute to this changing role. The aim was to investigate the feasibility of the developed training programs and e-learning training to enhance the active, supportive, and coaching role of occupational and insurance physicians needed for person-centered occupational health care. Information about this is important to facilitate implementation of the tools and training into educational structures and occupational health practice.MethodsA qualitative study was conducted, with N = 29 semi-structured interviews with occupational physicians, insurance physicians, and representatives from occupational educational institutes. The aim was to elicit feasibility factors concerning the implementation, practicality and integration with regard to embedding the training programs and e-learning training in educational structures and the use of the tools and acquired knowledge and skills in occupational health care practice after following the trainings and e-learning training. Deductive analysis was conducted based on pre-selected focus areas for a feasibility study.ResultsFrom an educational perspective, adapting the face-to-face training programs to online versions, good coordination with educational managers and train-the-trainer approaches were mentioned as facilitating factors for successful implementation. Participants underlined the importance of aligning the occupational physicians' and insurance physicians' competences with the educational content and attention for the costs concerning the facilitation of the trainings and e-learning training. From the professional perspective, factors concerning the content of the training and e-learning training, the use of actual cases from practice, as well as follow-up training sessions were reported. Professionals expressed good fit of the acquired skills into their consultation hour in practice.ConclusionThe developed training programs, e-learning training and accompanying tools were perceived feasible in terms of implementation, practicality, and integration by occupational physicians, insurance physicians and educational institutes.

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Delivering person-centered care with an electronic health record.

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Delivering person-centered care with an electronic health record.

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